It’s Time to Say “Thank You” to CRNAs!

Medical Business Management would like to join with the American Association of Nurse Anesthetists (AANA) in honoring Certified Registered Nurse Anesthetists during National CRNA week. The week of January 22-26 has been set aside to show appreciation for CRNAs and to raise awareness for the important work that they do.

CRNAs and Patients

CRNAs represent the personal side of anesthesiology. They are the ones that stay with the patient from start to finish during a medical procedure. They are likely to be the last face that you see when a procedure begins and the first face that you see as you regain consciousness. CRNAs are known for their personal touch. Many were drawn to this career because they enjoy the relationship with the patient and the role that they play in monitoring and maintaining each individuals wellbeing.

During a complicated medical procedure, there are a number of doctors and nurses involved in different aspects of your care. While many of these individuals are focused on specific tasks, the CRNA keeps a big picture perspective to ensure your overall well-being. This perspective can play a vital role in coordinating patient care and ensuring the best possible outcome. So as patients, we are happy to say, “Thank you CRNAs!”

Challenges Ahead for CRNAs

CRNAs in Georgia, Alabama, and Tennessee are facing new challenges. The migration from Cahaba GBA to Palmetto GBA has created a climate of uncertainty related to CRNAs and their status compared to anesthesiologists. Medical Business Management values our relationship with CRNAs nationwide, and we are committed to helping our clients navigate these uncertain times. Even if policies change, the expertise that we bring to practice management, coding, reimbursement, and billing will ensure that you are compensated fairly and in a timely manner.

Palmetto GBA Selected as Medicare Administrator for Jurisdiction J

The federal Centers for Medicare & Medicaid Services (CMS) has selected Palmetto GBA as the Medicare Administrative Contractor for Jurisdiction J. This jurisdiction, covering Alabama, Georgia, and Tennessee represents 7% of the national Part A/Part B claim-volume workload.

This change is having a dramatic impact on anesthesia practices across this 3 state regions. These practices have worked with Cahaba GBA for years, and the migration process will take some time.

What Your Anesthesia Practice Needs to Know about Transitioning to Palmetto GBA

Medical Business Management has thoroughly analyzed this process, and here are the key things that your practice needs to know about the transition from Cahaba GBA to Palmetto GBA. We have worked with Palmetto GBA for years supporting clients in other regions, and we believe that this change will be beneficial for anesthesia practices and CRNAs in Alabama, Tennessee, and Georgia, but the transition will be challenging and there are a number of pitfalls to avoid.

Claims Processing

All internal processing for Medicare claims has changed. Pay close attention to revised procedures for Palmetto GBA.

Online Tools

Palmetto GBA has a number of online tools that were not available through Cahaba GBA. Medical Business Management has used these online tools and features have enabled Medical Business Management to better serve our clients with coding and claims processing.

Is Palmetto Anti-CRNA?

Some CRNAs are concerned because the Palmetto’s manager is an anesthesiologist. It is possible that CRNAs will get cut out of some things. The best thing that CRNAs can do to manage the transition is to ensure accurate coding and compliance. Contact MBM today to find out more about how these changes might affect CRNAs.

Faster Time Frames

Credentialing takes an average of 60 days, but Cahaba GBA has been taking 120 days. They had a lot of employee turnover and they are trying to catch up using temporary employees. This strategy has not been effective to this point, but anesthesiologists should see an immediate improvement with the transition to Palmetto GBA.

Resources for the 3 Month Transition Period

Part B transition started on December 1, 2017, and the process will be complete on December 26, 2018. Our goal is to manage the transition process for our clients so that they don’t have to re-credential. This is a critical time for anesthesia practices and CRNAs. Do you have questions about the transition process? Contact us today to find out what you need to do to ensure a smooth process.

Could these changes result in rejected claims and unpaid charges? The answer is YES!

We are watching this transition closely and managing the transition process for our anesthesia providers. Since we have spent so much time working on MACRA, we thought that we would share the Top 5 Things that anesthesia providers need to know about how this will affect their practice.

The Top 5 Things Anesthesia Providers Need to Know About Medicare Beneficiary Identifiers

#1: MACRA requires removal Social Security Numbers (SSNs) from all Medicare cards by April 2019.

Health Insurance Claim Number (HICN) identifiers have come under increasing scrutiny because the prominent use of Social Security Numbers creates a significant risk for beneficiary identity theft. All beneficiaries will receive a new Medicare card by April of 2019.

#2: All beneficiaries will receive a new Medicare Beneficiary Identifier (MBI).

The new Medicare cards will replace the HICN with a Medicare Beneficiary Identifier (MBI) that doesn’t incorporate the SSN. MBI’s use the same number of digits as the HICN, and it will occupy the same fields. The MBI was designed to avoid commonly mistaken letters and numbers like “0” and “O”, and it is not based on the SSN in any way. This MBI is unique to each beneficiary.

#3: Transition period begins April 2018 through December 31, 2019.

Both numbers will work during that time. Starting on January 1, 2020, HICNs will no longer be exchanged with beneficiaries, providers, plans, and other 3rd parties. The HICN will only be used for appeal requests and related forms that were accepted using an HICN.

#5: Failure to comply with MACRA will prevent you from getting paid!

Starting on January 1, 2020, your claims will not be paid unless they are filed appropriately using the new MBI. Any claim submitted with the HICN will not be processed, resulting in significant delays in getting paid.

Anesthesia Providers and MACRA

Medical Business Management works with CRNA’s and Anesthesiologists to ensure that their claims are submitted accurately and paid in a timely manner. We navigate the complicated transition process and manage your revenue cycle so that you can focus on what you do best: serve your patients.

If you would you like to find out more about MACRA; Contact us today about how these changes will impact your revenue cycle.

The ABCs of Calculating Anesthesia Time Units

It’s essential to stay vigilant when it comes to calculating anesthesia time units. Not properly doing so can result indelayed or denied claims, decreased revenue, and audits – which can have a negative impact on your practice’s reputation.

Take a moment to look over this guide on the basics of calculating anesthesia time units so that your claims go through smoothly and accurately.

How to Determine and Report Anesthesia Time

Anesthesia time begins the moment the provider (the anesthetist) begins preparation for the patient, whether it’s in the operating room or in another area. An important thing to note is that any time spent looking over the patient’s medical records before surgery is not considered “anesthesia time” and is not billable. Instead, this is consideredpreoperative evaluation, and will be calculated in the base units.

The end of anesthesia time is marked by the moment the anesthetist is no longer personally attending the patient, and the patient has been moved into post-anesthetic care.

When it comes to the logistics of how one should report anesthesia time, the appropriate unit is 15-minute increments. Each 15-minute segment of anesthesia time is reported as one unit of time. So a 45-minute procedure would be considered three units of anesthesia time.

Accuracy is essential here, since Medicare pays to a tenth of a unit. Estimations of time are not appropriate. If the procedure lasts for 63 minutes, for example, then 4.2 time units would be reported – and that time should not be rounded up or down.

How to Calculate Reimbursement

There are specific formulas used to calculate reimbursement for a procedure based on the time units calculated for anesthesia time. The formula you use depends on who administered the anesthesia.

Again, accuracy is essential, as your process for calculating anesthesia time units can directly impact the overall charge, which then impacts your practice’s revenue.

What Else Should You Know About Calculating Anesthesia Time Units?

There are other considerations to be made here, too. For example, if there are interruptions in anesthesia care during a procedure, the exact times of the interruption should be recorded so that discontinuous time can be accounted for and any time that the anesthetist was not personally attending the patient will not be counted.

Additionally, most insurers will not allow for any more than one time unit for preparing patients for postoperative transfer to recovery. They also don’t allow you to bill for time that the patient is in a waiting room or another type of holding area. Patients also can’t be billed for any blood products or antibiotics that are given to them in a holding area, especially when those things could have been administered in a different part of the facility.

Questions about billing and coding?Get more information about how we can take that burden off your shoulders.

The ABCs of Physical Status Modifiers

Accuracy is essential when it comes to physical status modifiers in the anesthesiology field, and as of January 2016, the ASA Physical Status Classification System (modifiers P1-P6) includes examples to assist in choosing the appropriate modifier.

Theoriginal version was published in 1941 by Meyer Saklad, and then by ASA in a booklet for the members of its organization. In Saklad’s opinion, the pre-operative classification of a patient’s physical status was a very useful statistical tool, and he was adamant that “no attempt should be made to prognosticate the effect of a surgical procedure upon a patient of a given Physical State.”

In 1962, when the ASA published a revised version of Saklad’s system, it failed to include examples. Numerous studies have proven that clinicians’ assignments of PS modifiers are quite subjective and not prone to consistency, resulting in multiple PS classes assigned to the same patient.

A Wide Range of Uses

Now, the ASA PS Classification System is used for many purposes beyond the characterization of a patient’s physical status as it relates to anesthesiology. Things like paying for anesthesia services, allocating risk, and predicting perioperative risk are all included in those purposes. For this reason, the ASA chose to use the following examples in its system so that classifications become more uniform.

The more consistency we can have in physical status modifiers, the better, because everything from work assignments to finances are affected by them.

The ABCs of MAC Anesthesia

You may have heard about MAC anesthesia, or maybe you know someone who experienced this type of sedation during surgery – but what exactly is it, and how does it differ from general anesthesia? These are great questions, and they concern a lot of people – especially those who claim they’ve been awake during surgery.

Read on to learn the basics of MAC anesthesia.

What Is MAC Anesthesia?

MAC stands for Monitored Anesthesia Care. Rather than just knocking you out, anesthetic medications are used to put you through a range of sedation levels. The level you reach depends on a variety of things — like your age, health, genetic factors, and how much of the drug you are given.

According to The American Society of Anesthesiologists (ASA), levels of sedation are divided into the following four categories. Each category’s official ASA definition is given next to it.

Minimal Sedation – a drug-induced state during which patients respond normally to verbal commands.

Moderate Sedation – a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

Deep Sedation – a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.

General Anesthesia – a drug-induced loss of consciousness during which patients are not arousable even by painful stimulation.

MAC does not appear in these official classifications, but it is most closely associated with moderate and deep sedation.

Why Are There Levels of Sedation?

Since most people prefer to be completely unaware during surgery, it begs the question: what’s the point of minimal and moderate sedation? There are two main reasons lighter sedation is sometimes used: recovery is much quicker, and there is less depression of the patient’s breathing and heart rate (as opposed to heavier drugs, which cause the patient to gradually lose the ability to breathe normally).

The most important thing about MAC anesthesia is to have a clear understanding of the level of sedation you are being offeredbefore surgery. You should know exactly what to expect as far as your awareness and memory of the procedure (some anesthesia has the happy side effect of causing amnesia as far as the surgery goes).

Other problems can arise if the patient does not respond as expected to the sedation, and ends up either too lightly or too heavily sedated – but even with general anesthesia, there are about 2 in every 1,000 cases where patients are unintentionally aware.

MBM Supports Anesthesiology Practices

Our job is to handle your anesthesiology practice’s billing and coding so that you can focus on your patients, your staff, and your clinic.Contact us today for more information on how we can help!

The ABCs of CPT Modifiers

Because of the complexity of medical procedures and services, additional information is often necessary when coding. This information typically comes in the form of what’s called a CPT modifier, which describes how many procedures were performed, why they were necessary, where they were performed on the body, how many surgeons were involved in the operation, and more.

Below, we’ll go over the basics of CPT modifiers and how to use them correctly.

How Are CPT Modifiers Constructed?

CPT modifiers are always made up of two characters, either numeric or alphanumeric. Most are numeric, butsome anesthesia modifiers are alphanumeric.

These modifiers are attached to the end of a CPT code without a hyphen. If you have more than one modifier, you’ll code the “functional” one first, followed by the “informational” one. How can you tell the difference? It’s easy – list the modifier that affects the reimbursement process the most directly first.

Why Does Order Matter?

The reason we list modifiers in a certain order is that payers don’t always consider modifiers after the first two. (CMS-1500 and UB-04 provide space for four modifiers, though.) Because of this, the first two modifiers are the most important ones, and you want to make sure they are visible.

What’s an Example of a CPT Modifier in Anesthesia?

Anesthesia has its own special set of modifiers that correspond tothe patient’s condition as anesthesia is administered. The following is a list of these codes:

P1 – a normal, healthy patient

P2 – a patient with mild systemic disease

P3 – a patient with severe systemic disease

P4 – a patient with severe systemic life-threatening disease

P5 – a moribund patient who is not expected to survive without the operation

These codes are pretty straightforward, but let’s consider an example of how they might be used. If a patient needs to be anesthetized before undergoing a procedure, then you would turn to the appropriate section of the CPT codebook and find the correct code that you need. If your patient is otherwise in good health, you would add the P1 modifier to your code.

Need Help with Your Coding and Billing? Contact MBM Today!

If you’re ready to let Medical Business Management worry about your practice’s coding and billing so that you can focus on your patients,contact us to start a conversation about our services. We are ready to remove that burden from your shoulders – and there’s no one better able to handle it than us!

Regional Anesthesia Has Positive Impact on Bundled Payments

Regionalanesthesia has been shown to have a positive impact on pain scores, length of stay, postoperative nausea and vomiting, time in post-anesthesia care, and opioid use / adverse events. And according to Sonia Szlyk, MD, speaker at the Interdisciplinary Conference on Orthopedic Value-Based Care, it has also shown to have a positive impact on bundled payment programs.

Avoiding Opioids

“One of the reasons why regional is so impactful is because it allows us to be opioid sparing,” Szlyk said. “Opioid-related adverse events are costly and common. If you can do anything to reduce the patient’s need for opioids or reduce the risk of opioid-related adverse events, you are going to be more successful in a positive bundle payment scenario.”

According to a study published in Pain & Palliative Care Pharmacology, 12.2% of 320,000 patients who underwent a total hip or total knee replacement experienced an opioid-related adverse event. As noted by Szlyk, this added a substantial cost to the system and would destroy the bundle. This was because patients stayed in the hospital 3.3 days longer; hospital costs increased $4,707 on average, and the 30-day readmission rate rose.

According to a meta-analysis in Regional Anesthesia and Pain Medicine, the incidence of surgical site infections was decreased with neuraxial anesthesia as opposed to general anesthesia. And another study published in Anesthesiology that included over 380,000 patients who had undergone total hip or knee replacements at 400 different hospitals showed a decreased rate of 30-day mortality and in-hospital complications with neuraxial anesthesia compared with general anesthesia.

MBM Cares About Anesthesiologists and CRNAs

When it comes to navigating the world ofvalue-based care and bundled payments, nobody knows the industry better than Medical Business Management. Contact us today for more information on how we can take the billing and coding burden off your shoulders so you can focus on your practice.

3 Things Physicians Will Bring Before State Legislators This Year

As physicians enter 2017, there are a number of concerns that will occupy their advocacy efforts for the year. In a survey of more than 65 state and specialty societies, the top issues for 2017 include the nation’s opioid epidemic, Medicaid expansion, private payer reforms, and numerous public health issues.

Below are three issues physicians will advocate for in 2017.

#1: Medicaid

Many states are buckling up for debates surrounding Medicaid’s expansion, as well as for Medicaid reforms to improve patient access and quality of care.

As for funding, Alabama, California, Illinois, Michigan, Mississippi, Ohio, Oklahoma, Oregon, and Wyoming are just a handful of the many states dealing with issues concerning Medicaid.

#2: Opioid Epidemic

Across the country, physicians will continue to fight against opioid misuse, overdose, and death. A lot of this legislation will focus on the use of the mandated prescription drug monitoring program (PDMP), better physician education, substance-use disorder treatment, and guidelines or limitations on the prescription of controlled substances.

As has been previously done, many states will focus on PDMPs. Additionally, states will keep considering proposals that advocate for increased access to naloxone. They will also go after stronger Good Samaritan policies for those who assist someone experiencing an overdose.

#3: Provider Networks

Out-of-network care and network adequacy will continue to be major issues in 2017, as networks narrow and patients find themselves footing more bills out of pocket. Physicians are talking to key stakeholders all over the country about offering quality, affordable care to patients while still staying eligible for fair contract negotiations.

There are more than two dozen state medical societies that will address out-of-network billing this year, specifically within the hospital setting. And there are nearly the same number of states considering proposals to address the adequacy of these provider networks.

MBM Supports Physicians

Because most physicians are working to settle legislative concerns and remain focused on the clinical side of healthcare, they hardly have timeto worry about billing and coding. That’s where Medical Business Management comes in – to keep physician focus on the patients and not the paperwork.Contact us today for more information!

In the letter, Joel H. Rubenstein, MD, MSc, of the department of Veterans Affairs, VA Ann Arbor Healthcare System, and the department of internal medicine at University of Michigan Health System, and his colleagues, stated: “While our results demonstrate that [monitored anesthesia care (MAC)] use did indeed increase in the VHA over the study period, the overall rate of MAC use in the VHA is substantially lower than that observed in fee-for-service environments, further supporting the existence of prominent financial drivers in the growing use outside the VHA.”

The Ins and Outs of Monitored Anesthesia Care

MAC requires an anesthesiology professional and, typically, is done using propofol. Compared with endoscopist-directed sedation that uses short-acting opioids and benzodiazepines, propofol leads to deeper sedation.

According to previous research, more than 50 percent of MAC use occurs in low-risk patients who are having routine endoscopic procedures done, in spite of current guideline recommendations stating that MAC isn’t a cost-effective option for these patients. For that reason, Rubenstein and his colleagues examined MAC use within the VHA in order to have a fuller understanding of the motivation behind increased MAC use.

The Study

Together with his colleagues, Rubenstein conducted a retrospective cohort study of over 2 million veterans who had undergone more than 3.5 million outpatient esophagogastroduodenoscopies (EGD) or colonoscopies at a VHA facility. The time frame was from fiscal year 2000 through 2013, the mean age was 62.8 years, and 94.7% of the veterans were men.

MAC use more than doubled from 4% in fiscal year 2000 to 9.3% in 2013, and began a steady increase in 2008.

In fiscal year 2000, the median facility use of MAC was 0.11% vs. 3.52% in 2013. This varied widely from one facility to the next, especially once the study period was coming to an end.

Rubenstein and colleagues wrote that aside from financial incentives, this increase in MAC use may have been driven by “changes in patient characteristics, such as increased veteran comorbidities or use of prescription opioids (which may confer intolerance to standard sedatives), [and] organizational factors influencing health care delivery, including practice culture, patient preference for MAC, and increased availability of MAC in the VHA.”

They went on to say: “Understanding the presence and degree of inappropriate use of MAC inside and outside the VHA will help promote efficient use of resources and ensure delivery of high-value care.”

The Continuing Case for Bundled Care

The findings of this study support the utilization of bundled payments as a tool to reduce the use of low-value services. This conclusion comes froma related letter by Lee A. Fleisher,MD,of the Leonard Davis Institute of Healthcare Economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

In this letter, Fleisher states: “Our first obligation to our veterans is to ensure that they are truly getting the best care and are satisfied with the care. Once that is ensured, and if the current findings simply reflect financial drivers on current practice, then the present article adds to the growing recommendations that bundled care for endoscopy has the potential to lead to delivering the best value: optimal care at the least cost.”

He went on to say that “If gastroenterologists, anesthesiologists, and facilities receive a set fee for the endoscopy procedure and the anesthesia and/or sedation services, then the incentive to provide anesthesia, in situations in which it is not needed, will be eliminated. However, to achieve the goal of getting the most value for our health care dollars, we need a better understanding of the value of anesthesiology vs. moderate sedation for performing endoscopy.”

Category: Anesthesia Billing

Medical Business Management would like to join with the American Association of Nurse Anesthetists (AANA) in honoring Certified Registered Nurse Anesthetists during National CRNA week. The week of January 22-26 has been set aside to show appreciation for CRNAs and to raise awareness for the important work that they do. CRNAs and Patients CRNAs represent […]

The federal Centers for Medicare & Medicaid Services (CMS) has selected Palmetto GBA as the Medicare Administrative Contractor for Jurisdiction J. This jurisdiction, covering Alabama, Georgia, and Tennessee represents 7% of the national Part A/Part B claim-volume workload. This change is having a dramatic impact on anesthesia practices across this 3 state regions. These practices […]

The Medicare Access and CHIP Reauthorization Act of 2015, commonly known as MACRA is bringing dramatic changes for Medicare beneficiaries and the providers that serve them. MACRA is bringing big changes for anesthesiologists and CRNA’s. Could these changes result in rejected claims and unpaid charges? The answer is YES! We are watching this transition closely […]

It’s essential to stay vigilant when it comes to calculating anesthesia time units. Not properly doing so can result in delayed or denied claims, decreased revenue, and audits – which can have a negative impact on your practice’s reputation. Take a moment to look over this guide on the basics of calculating anesthesia time units […]

Accuracy is essential when it comes to physical status modifiers in the anesthesiology field, and as of January 2016, the ASA Physical Status Classification System (modifiers P1-P6) includes examples to assist in choosing the appropriate modifier. The original version was published in 1941 by Meyer Saklad, and then by ASA in a booklet for the […]

You may have heard about MAC anesthesia, or maybe you know someone who experienced this type of sedation during surgery – but what exactly is it, and how does it differ from general anesthesia? These are great questions, and they concern a lot of people – especially those who claim they’ve been awake during surgery. […]

Because of the complexity of medical procedures and services, additional information is often necessary when coding. This information typically comes in the form of what’s called a CPT modifier, which describes how many procedures were performed, why they were necessary, where they were performed on the body, how many surgeons were involved in the operation, […]

Regional anesthesia has been shown to have a positive impact on pain scores, length of stay, postoperative nausea and vomiting, time in post-anesthesia care, and opioid use / adverse events. And according to Sonia Szlyk, MD, speaker at the Interdisciplinary Conference on Orthopedic Value-Based Care, it has also shown to have a positive impact on […]

As physicians enter 2017, there are a number of concerns that will occupy their advocacy efforts for the year. In a survey of more than 65 state and specialty societies, the top issues for 2017 include the nation’s opioid epidemic, Medicaid expansion, private payer reforms, and numerous public health issues. Below are three issues physicians […]

Monitored anesthesia care in routine GI endoscopy has increased within the VHA, but remains low outside of it. This statistic was revealed in a research letter published in JAMA Internal Medicine. In the letter, Joel H. Rubenstein, MD, MSc, of the department of Veterans Affairs, VA Ann Arbor Healthcare System, and the department of internal […]